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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440339
Report Date: 06/14/2024
Date Signed: 06/14/2024 05:25:23 PM

Document Has Been Signed on 06/14/2024 05:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PIROUNAKIS, INC.FACILITY NUMBER:
011440339
ADMINISTRATOR/
DIRECTOR:		MARY PIROUNAKISFACILITY TYPE:
735
ADDRESS:17031 RAGLAND ST.TELEPHONE:
(510) 276-2301
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 12CENSUS: 11DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:22 AM
MET WITH:Margaret 'Rita' Revill/Co-administratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On this day, June 14, 2023, at 10:22 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Rowena Velasco, and informed the reason for visit. LPA called and spoke over the phone with Mary Pirounakis, administrator, who stated she is with residents for appointments, and Margarita 'Rita' Revill, co-administrator, is coming to the facility. Co-administrator arrived at 10:50 a.m.

Facility submitted the LIC9282 Infection Control Plan on June 8, 2023

LPA started the inspection with the staff and continued with co-administrator. LPA inspected the kitchen, dining area, living room, tv room, bedrooms, bathrooms, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced March 20, 2024. Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed functional. Hot water temperature in one the common bathrooms was tested and measured at 110.9 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted May 10, 2024.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff and 2 residents. P&I money checked and compared with last recorded balance. Medications were inspected and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders on file.

LPA observed the following:
-at 10:31 a.m., expired protein drink (expiration dates: 8/29/23 & 6/02/21) and 2 bottles of classic cream (expiration dates: 2/04/24; 9/17/23).

....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339
VISIT DATE: 06/14/2024
NARRATIVE
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-at 2:30 p.m., all 5 residents have no LIC9172 Functional Capability Assessment on file.
-at 2:50 p.m., 4 out of 5 residents are over 60 years of age. LPA verified, and per co-administrator, 6 out of 11 residents are 60 or over years of age.-
-at 3:10 p.m., resident (R1) has Ferrous Sulfate medication. but no doctor's order on file.
-at 3:25 p.m., resident (R2) order for 11 medications do not have the frequency of administration.

LPA received the following current/updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with co-administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/14/2024 05:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/14/2024 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in resident's (R1) Ferrous Sulfate not having doctor's order which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
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Corrected.
Co-administrator obtained doctor's order while LPA was at the facility.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/14/2024 05:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/14/2024 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)(2)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information: (2) The exact dosage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based onn record review, the licensee did not comply with the section cited above in resident (R2) order for 11 medications not having the frequency of administration which poses an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
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Co-administrator to obtain complete doctor's order and submit proof by 6/15/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/14/2024 05:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/14/2024 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents not having LIC9172 which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Co-administrator to complete the LIC9172 and submit self-certificaiton by 6/28/24.
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, the licensee did not comply with the section cited above in exceeding 25% of the census who are over 60 years of age which poses a potential health and /or personal rights risks to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Co-administrator stated she'll submit age exception requests . Request letters along with supporting documents to be submitted by 6/28/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/14/2024 05:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/14/2024 at 04:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in expired protein drink and cream which pose an immediate health and/or personal rights risks to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
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Staff threw away the expired items.
In addition, co-administrator to in-service the staff and submit copy of training topic with attendees' signatures by 6/15/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
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